Background:
Opioid analgesics have served as the cornerstone of acute and chronic pain management in patients with sickle cell disease (SCD) in the United States. Despite significant opioid use, ...hospitalization for painful crises comprises the majority of healthcare costs for patients with SCD. Moreover, greater use of opioids may correlate with poorer response to treatment of acute painful crises. Insufficient pain management, the rise of opioid use disorder and opioid-related fatal overdose have opened the door for new strategies of pain management for these patients. Medical cannabis represents a potential new strategy for the management of chronic SCD pain. There is a substantial body of literature describing the analgesic properties of cannabis, but little research has explored its role in the management of SCD-related pain. We sought to evaluate the prevalence of marijuana use in an urban SCD patient population and to identify demographic and clinical characteristics that may predict marijuana use in this cohort.
Methods:
Adult patients with SCD seen at an urban outpatient SCD center completed an intake form with questions regarding individual demographics, cumulative disease complications, current or prior marijuana use, ED utilization, frequency of pain, and opioid use. Data from 78 patients seen between October 2017 and June 2018 were available for analysis. Additional data including information regarding disease genotype and race were collected from the electronic medical record. Data were analyzed using Microsoft Excel and Chi-Square analysis.
Results:
Among the 78 patients, mean age of the population was 35.7 years (range 20-69), and 50% were male. Genotype was 69% HbSS/SB0 and 31% HbSC/SB+. Twenty-three patients (29%) reported ever using marijuana, and 15 (19%) endorsed current use; most patients (80%) reported smoking. Marijuana users were more likely than non-users to be male (67% v 46%), to have HbSS/SB0 (80% v 67%), to have avascular necrosis (AVN) (47% v 17%, p=.025), to report daily pain (40% v 13%, p=.013), and to be prescribed opioids (93% v 65%, p=.031). Frequent ED visits (at least monthly) were more common in marijuana users (33% v 6% p=.002) compared to non-users. Age, leg ulcers, priapism, and hydroxyurea use were not different in users versus non-users.
Discussion:
In this cohort of patients with SCD seeking outpatient care, 19% reported current marijuana use for the management of SCD-related symptoms. Most patients reported smoking marijuana, and only one patient reported ingestion of edible marijuana. These rates are similar to marijuana use in other populations with chronic pain. SCD marijuana users were similar in age but not in sex distribution, as men more commonly reported marijuana use than women in our population. Marijuana users were enriched for the HbSS genotype, reported more daily pain, had more frequent ED visits and were more likely to be diagnosed with AVN of bones. There was a strong association between marijuana use and self-reported opioid use for pain control. These preliminary data suggest that patients with more severe manifestations of SCD, namely daily pain, frequent ED visits, AVN of bones, and significant utilization of opioids, are more likely to be using marijuana as adjunctive therapy for their chronic pain.
As of July 2018, 31 US states and the District of Columbia have legalized the use of medical cannabis, with chronic pain an indication in most states and opioid replacement an indication in some. The expansion of access to medical cannabis highlights the need for careful evaluation of the potential benefits and harms of medical cannabis in the SCD population. These benefits might include better control of daily pain, reduced visits to the ED, and possibly decreased utilization of opioids. As medical cannabis is becoming a more available therapy, carefully controlled prospective studies are needed to assess its efficacy in the management of debilitating symptoms of SCD.
Display omitted
Starrels:Opioid Post-Marketing Requirement Consortium: Other: Research and travel support from the Opioid Post-Marketing Requirement Consortium for a FDA-mandated observational study of the risks of opioid medications. Minniti:Novartis: Membership on an entity's Board of Directors or advisory committees; Bluebird Bio: Other: Adjudicating Committee; Global Blood Therapeutics: Research Funding; Teutona: Membership on an entity's Board of Directors or advisory committees; Bayer: Research Funding.
Medical cannabis policies are changing in many places around the world, and physicians play a major role in the implementation of these policies. The aim of this study was to gain a deeper ...understanding of physicians’ views on medical cannabis and its possible integration into their clinic, as well as to identify potential underlying factors that influence these perceptions.
Qualitative narrative analysis of in-depth interviews with twenty-four Israeli physicians from three specialties (pain medicine, oncology and family medicine).
Physicians disclosed contrasting narratives of cannabis, presenting it as both a medicine and a non-medicine. These divergent positions co-existed and were intertwined in physicians’ accounts. When presenting cannabis as a non-medicine, physicians drew on conventional medicine and prohibition as narrative environments. They emphasized the incongruence of cannabis with standards of biomedicine and presented cannabis as an addictive drug of abuse. In contrast, physicians drew upon unconventional medicine and palliative care as narrative environments while presenting cannabis as a medicine. In this narrative, physicians emphasized positive hands-on experiences with cannabis, and pointed to the limits of conventional medicine.
Physicians did not have a consolidated perspective as to whether cannabis is a medicine or not, but rather struggled with this question. The dualistic narratives of cannabis reflect the lack of a dominant narrative environment that supports the integration of cannabis into medical practice. This may in turn indicate barriers to the implementation of medical cannabis policies. An awareness of physicians’ views and the different levels of their willingness to implement medical cannabis policies is essential for policy developments in this evolving field.
Since the passage of the 2018 Farm Bill, practitioners have encountered more patients self-treating pain with over-the-counter topical cannabidiol (CBD) derived from hemp-Cannabis sativa with less ...than 0.3% delta-9-tetrahydrocannabinol-with reported improvements in pain control and activities of daily living. Cannabidiol has been touted for its capacity to improve inflammatory, arthritic, and neuropathic pain conditions, and increasing numbers of patients are exploring its use as potential replacement for opioids. However, limited rigorous clinical trials have been performed evaluating the safety and efficacy of cannabinoids for the treatment of pain.
A systematic search of PubMed was performed using the Medical Subject Headings (MeSH) terms "cannabinoid" or "CBD" or "cannabidiol" or "cannabis" or "medical marijuana" and "pain." It yielded 340 article titles. Twelve full-text primary studies of oral or topical CBD for chronic pain were selected for review, including 6 animal (2 randomized clinical trial and 4 prospective trials) and 6 human (4 randomized clinical trial and 2 prospective trials) studies.
With respect to the safety and efficacy of oral and topical CBD for treating pain, animal and human studies have shown early positive results with limited minor side effects. However, all human studies may be underpowered with small sample sizes.
With respect to the safety and efficacy of oral and topical CBD for treating pain, the evidence remains inconclusive in that we have a paucity of data to share with our patients who are considering the use of these products, which may be associated with significant costs.
Legislative changes in the last years have made possible the prescription of medical cannabis in several countries, often following a growing public demand. However, the medical indications for use ...and the access to prescribed cannabis are still limited. Prescribers face several challenges in the form of barriers and dilemmas, often related to stigma, and deficient information and training. As a result, many people keep on using illicit cannabis for medical problems. In this session we will outline the most common controversies of cannabis prescription, particularly in psychiatry. We will discuss the ethical considerations regarding prescription practices, the benefit-risk assessment, the limitations of the current knowledge, and some potential solutions to respond to the strong demand from patients and families. Disclosure No significant relationships.
Cannabis has been widely used as a medicinal agent in Eastern medicine with earliest evidence in ancient Chinese practice dating back to 2700 BC. Over time, the use of medical cannabis has been ...increasingly adopted by Western medicine and is thus a rapidly emerging field that all pain physicians need to be aware of. Several randomized controlled trials have shown a significant and dose-dependent relationship between neuropathic pain relief and tetrahydrocannabinol - the principal psychoactive component of cannabis. Despite this, barriers exist to use from both the patient perspective (cost, addiction, social stigma, lack of understanding regarding safe administration) and the physician perspective (credibility, criminality, clinical evidence, patient addiction, and policy from the governing medical colleges). This review addresses these barriers and draws attention to key concerns in the Canadian medical system, providing updated treatment approaches to help clinicians work with their patients in achieving adequate pain control, reduced narcotic medication use, and enhanced quality of life. This review also includes case studies demonstrating the use of medical marijuana by patients with neuropathic low-back pain, neuropathic pain in fibromyalgia, and neuropathic pain in multiple sclerosis. While significant preclinical data have demonstrated the potential therapeutic benefits of cannabis for treating pain in osteoarthritis, rheumatoid arthritis, fibromyalgia, and cancer, further studies are needed with randomized controlled trials and larger study populations to identify the specific strains and concentrations that will work best with selected cohorts.
Low back pain (LBP) occurs in many patients with fibromyalgia (FM). The current study aimed to assess the possible pain and function amelioration associated with medical cannabis therapy (MCT) in ...this setting.
31 patients were involved in an observational cross-over study. The patients were screened, treated with 3 months of standardised analgesic therapy (SAT): 5 mg of oxycodone hydrochloride equivalent to 4.5 mg oxycodone and 2.5 mg naloxone hydrochloride twice a day and duloxetine 30 mg once a day. Following 3 months of this therapy, the patients could opt for MCT and were treated for a minimum of 6 months. Patient reported outcomes (PRO's) included: FIQR, VAS, ODI and SF-12 and lumbar range of motion (ROM) was recorded using the modified Schober test.
While SAT led to minor improvement as compared with baseline status, the addition of MCT allowed a significantly higher improvement in all PRO's at 3 months after initiation of MCT and the improvement was maintained at 6 months. ROM improved after 3 months of MCT and continued to improve at 6 months.
This observational cross-over study demonstrates an advantage of MCT in FM patients with LBP as compared with SAT. Further randomised clinical trial studies should assess whether these results can be generalised to the FM population at large.
Issue
On 17 October 2018, Canada legalised non‐medical cannabis. Critically, the cannabis market in Canada has changed considerably since legalisation. In this scoping review, we identified available ...evidence on changes in cannabis‐related health harms following legalisation and contextualised findings based on legal market indicators.
Approach
Electronic searches were conducted to identify studies that compared changes in cannabis‐related health harms pre‐ and post‐legalisation. We contextualised each study by the mean per capita legal cannabis stores and sales during the study period and compared study means to per capita stores and sales on October 2021—3 years following legalisation.
Implications and Conclusions
Some measures of cannabis harms have increased since legalisation but studies to date have captured periods of relatively low market maturity. Longer‐term monitoring of health harms as the market continues to expand is indicated.
Introduction
An increasing number of countries are inthe process of legalising non‐medical cannabis. We described how the legal market has changed over the first 4 years following legalisation in ...Canada.
Methods
We collected longitudinal data on operating status and location of all legal cannabis stores in Canada for the first 4 years following legalisation. We examined per capita stores and sales, store closures, and the drive time between stores and each neighbourhood in Canada. We compared measures between public and private retail systems.
Results
Four years after legalisation, there were 3305 cannabis stores open in Canada (10.6 stores per 100,000 individuals aged 15+ years). Canadians spent $11.85CAD a month on cannabis per individual aged 15+ years, and 59% of neighbourhoods were within a 5‐minute drive of a cannabis store. Over 4 years, per capita stores and per capita sales increased each year by an average of 122.3% and 91.7%, respectively, with larger increases in private versus public systems (4.01 times greater for per capita stores and 2.46 times greater for per capita sales). The annual increase in per capita stores and sales during the first 3 years was 6.0 and 15.5 times greater, respectively, than the increase in the fourth year following legalisation. Over 4 years, 7% of retail store locations permanently closed.
Discussion and Conclusion
The legal cannabis market in Canada expanded enormously over the first 4 years following legalisation, with considerable variation in access between jurisdictions. The rapid retail expansion has implications for evaluation of health impacts of non‐medical legalisation.
Certifications for medical cannabis are generally restricted to a small number of specific medical conditions, yet patients frequently report symptoms of pain, anxiety, and depression as reasons for ...use. This is a critical concern for researchers, healthcare providers, and policymakers, yet research in this area is currently obstructed by the lack of a focused review or empirical synthesis on patient-reported reasons for medical cannabis use.
AND METHOD: The first aim of this project was to conduct the first systematic review and meta-analysis of empirical studies of patient-reported symptoms of pain, anxiety, and depression as reasons for medical cannabis use. The second aim was to conduct an empirical assessment of the methodological quality of extant research, test for publication bias, and test sex composition and quality scores of individual studies as possible sources of observed heterogeneity.
Meta-analytic results indicated that pain (64%), anxiety (50%), and depression/mood (34%) were common reasons for medical cannabis use. No evidence for publication bias was detected, despite heterogeneity in prevalence rates. A comprehensive assessment of study quality identified a number of specific methodological limitations of the existing research, including challenges in patient recruitment, use of restrictive sampling frames, and a lack of randomized recruitment methods and validated assessment measures.
Findings are discussed with regard to possible explanations for current results, clinical considerations, and areas of future research that are needed to move the field forward.
•Systematically reviewed studies why patients use medical cannabis.•Pain was a common reason for medical cannabis use (64%).•Anxiety (50%) and depression (34%) were also common reasons for use.•Prevalence rates were heterogeneous; no apparent publication bias.•Review offers specific directions for future research.
PDF
